Pancreatic pseudocyst GUIDELINES CLINICAL PRACTICE Dr. Peter V Draganov,

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[email protected]
doi:10.3748/wjg.15.38
World J Gastroenterol 2009 January 7; 15(1): 38-47
World Journal of Gastroenterology ISSN 1007-9327
© 2009 The WJG Press and Baishideng. All rights reserved.
GUIDELINES CLINICAL PRACTICE
Dr. Peter V Draganov, Series Editor
Pancreatic pseudocyst
Samir Habashi, Peter V Draganov
Samir Habashi, Peter V Draganov, Department of
Gastroenterology Hepatology and Nutrition, University of
Florida, Gainesville, Florida 32610, United States
Author contributions: Habashi S and Draganov PV contributed
equally to this work.
Correspondence to: Peter V Draganov, MD, Department
of Gastroenterology, Hepatology and Nutrition, University of
Florida, 1600 SW Archer Rd, Room HD 602, PO Box 100214
Gainesville, Florida 32610,
United States. [email protected]
Telephone: +1-352-3922877 Fax: +1-352-3923618
Received: June 8, 2008
Revised: October 2, 2008
Accepted: October 9, 2008
Published online: January 7, 2009
Abstract
Pancreatic pseudocysts are complications of acute or
chronic pancreatitis. Initial diagnosis is accomplished
most often by cross-sectional imaging. Endoscopic
ultrasound with fine needle aspiration has become
the preferred test to help distinguish pseudocyst from
other cystic lesions of the pancreas. Most pseudocysts
resolve spontaneously with supportive care. The size
of the pseudocyst and the length of time the cyst has
been present are poor predictors for the potential of
pseudocyst resolution or complications, but in general,
larger cysts are more likely to be symptomatic or cause
complications. The main two indications for some type
of invasive drainage procedure are persistent patient
symptoms or the presence of complications (infection,
gastric outlet or biliary obstruction, bleeding). Three
different strategies for pancreatic pseudocysts drainage
are available: endoscopic (transpapillary or transmural)
drainage, percutaneous catheter drainage, or open
surgery. To date, no prospective controlled studies
have compared directly these approaches. As a result,
the management varies based on local expertise,
but in general, endoscopic drainage is becoming the
preferred approach because it is less invasive than
surgery, avoids the need for external drain, and has
a high long-term success rate. A tailored therapeutic
approach taking into consideration patient preferences
and involving multidisciplinary team of therapeutic
endoscopist, interventional radiologist and pancreatic
surgeon should be considered in all cases.
© 2009 The WJG Press and Baishideng. All rights reserved.
Key words: Pancreatic pseudocyst; Cyst; Pancreatititis;
Endoscopic ultrasound; Therapy
Peer reviewer: Luis Bujanda, Professor, Donostia Hospital,
Avda. Sancho El Sabio 21-3C, San Sebastián, 20010, Spain
Habashi S, Draganov PV. Pancreatic pseudocyst. World J
Gastroenterol 2009; 15(1): 38-47 Available from: URL: http://
www.wjgnet.com/1007-9327/15/38.asp DOI: http://dx.doi.
org/10.3748/wjg.15.38
INTRODUCTION
Pseudocyst of the pancreas is a localized fluid collection
that is rich in amylase and other pancreatic enzymes and
is surrounded by a wall of fibrous tissue that is not lined
by epithelium[1]. Pseudocysts are connected with the
pancreatic duct system, either as a direct communication
or indirectly via the pancreatic parenchyma. They
are caused by pancreatic ductal disruption following
increased pancreatic ductal pressure, either due to
stenosis, calculi or protein plugs obstructing the main
pancreatic ductal system, or as a result of pancreatic
necrosis following an attack of acute pancreatitis[2,3].
Pseudocysts are a common clinical problem and
complicate the course of chronic pancreatitis in 30% to
40% of patients[4].
ETIOLOGY
The occurrence of pseudocyst parallels that of
pancreatitis and the etiology of pseudocysts resembles
the causes of pancreatitis closely, although pseudocyst
formation is less common after acute compared to
chronic pancreatitis, and it is more common after
alcohol-induced than after non-alcohol-related
pancreatitis. Alcohol-related pancreatitis appears to be
the major cause in studies from countries where alcohol
consumption is high and accounts for 59%-78% of all
pseudocysts[5].
Walt et al[6] reported data collected from Wayne State
University Hospital in Detroit, USA. The causative
factors in the 357 admissions for pancreatic pseudocysts
included alcohol use in 251 cases (70%), biliary tract
disease in 28 (8%), blunt trauma in 17 (5%), penetrating
trauma in four (1%), operative trauma in one (0.3%),
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Habashi S et al . Pancreatic pseudocyst
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and idiopathic in 56 (16%). Most of the patients in the
idiopathic group were thought to have been alcoholrelated, but no definite evidence was recorded[6].
CLASSIFICATION
D’Egidio and Schein, in 1991, described a classification
of pancreatic pseudocyst based on the underlying
etiology of pancreatitis (acute or chronic), the pancreatic
ductal anatomy, and the presence of communication
between the cyst and the pancreatic duct[7]. They define
three distinct types of pseudocysts[7]. Type Ⅰ, or acute
“post-necrotic” pseudocysts, that occur after an episode
of acute pancreatitis and are associated with normal duct
anatomy, and rarely communicate with the pancreatic
duct. Type Ⅱ, also post-necrotic pseudocysts, which
occurs after an episode of acute-on-chronic pancreatitis
(the pancreatic duct is diseased, but not strictured,
and there is often a duct-pseudocyst communication).
Type Ⅲ, defined as “retention” pseudocysts, occur with
chronic pancreatitis and are uniformly associated with
duct stricture and pseudocystduct communication.
Another classification, based entirely on pancreatic
duct anatomy, is proposed by Nealon and Walser [8].
Type Ⅰ: normal duct/no communication with the cyst.
Type Ⅱ: normal duct with duct-cyst communication.
Type Ⅲ: otherwise normal duct with stricture and no
duct-cyst communication. Type Ⅳ: otherwise normal
duct with stricture and duct-cyst communication. Type Ⅴ:
otherwise normal duct with complete cut-off. Type Ⅵ:
chronic pancreatitis, no duct-cyst communication. Type Ⅶ:
chronic pancreatitis with duct-cyst communication[8].
INCIDENCE
Regardless of the etiology of pseudocyst, the incidence
is low, 1.6%-4.5%, or 0.5-1 per 100 000 adults per
year[9,10]. In a study by Imrie, pseudocysts developed
after emergency hospital admission for an episode of
acute pancreatitis in 86 patients [11]. Sixty-two of the
86 pseudocysts consequent to acute pancreatitis were
derived from the local hospital population area, in which
879 patients with acute pancreatitis were admitted to
hospital during the same time period. This resulted in a
7% overall incidence of pseudocysts as a complication
of acute pancreatitis[11].
In a series of 926 patients with non-alcoholic acute
pancreatitis, fluid collections were observed in 83 (9%).
At the end of 6 wk, 48 (5%) still had a fluid collection
consistent with a pseudocyst[12].
Kourtesis et al [13] followed prospectively with
computed tomography (CT) 128 consecutive patients
with acute pancreatitis (mostly alcohol-induced). Fortyeight patients (37%) developed fluid collection in the
pancreatic region. The majority of these resolved
spontaneously. In 15 (12%) patients, symptomatic
pseudocysts developed.
Pseudocysts tend to be more common in chronic as
compared to acute pancreatitis. Incidence figures of 30%
to 40% have been reported in the literature[4]. However,
Table 1 Differential diagnosis of pancreatic pseudocyst
Pancreatic diseases
Extrapancreatic diseases
Acute & chronic pancreatitis
Pancreatic necrosis & abscess
Adenocarcinoma of the pancreas
Pancreatic cystic neoplasms
Pancreatic artery pseudoaneurysm
Peptic ulcer disease & gastric cancer
Acute cholecystitis & gallstones
Abdominal aortic aneurysm
Intestinal ischemia
Ovarian cysts & cancers
Bowel obstruction
Acute myocardial infarction
Pneumonia
there is a lack of precise data based on the long-term
follow-up of patients with chronic pancreatitis, in contrast
to acute pseudocysts where the patient with chronic
pancreatitis may have had the disease for 10, 20 or more
years giving him a high risk of developing a pseudocyst at
least once over a long period of sickness[14].
PATHOGENESIS
The pathogenesis of pseudocysts seems to stem from
disruptions of the pancreatic duct due to pancreatitis
or trauma followed by extravasation of pancreatic
secretions. Two thirds of patients with pseudocysts
have demonstrable connections between the cyst and
the pancreatic duct. In the other third, an inflammatory
reaction most likely sealed the connection so that it is
not demonstrable.
In case of pseudocyst following an episode of acute
pancreatitis, only if the acute fluid collection persists
more than 4-6 wk, and is well-defined by a wall of
fibrous or granulation tissue, can one say that an acute
pseudocyst has appeared. Such a pseudocyst usually
contains enzymatic fluid and necrotic debris[1,5].
The pathogenesis of pseudocyst formation in
chronic pancreatitis is less well understood but, at least
two mechanisms may be involved, the cyst may develop
as a consequence of an acute exacerbation of the
underlying disease and/or blockage of a major branch
of the pancreatic duct by a protein plug, calculus or
localized fibrosis[15].
CLINICAL PRESENTATION, DIAGNOSIS
AND DIFFERENTIAL DIAGNOSIS
The clinical presentation of pancreatic pseudocyst
can range from asymptomatic patient to major
abdominal catastrophe due to complications[16-18]. Acute
complications include bleeding (usually from splenic
artery pseudoaneurysm), infection, and rupture.
Chronic complications include gastric outlet
obstruction, biliary obstruction and thrombosis of
the splenic or portal vein with development of gastric
varices[18].
A variety of diseases can mimic the clinical
presentation of pancreatic pseudocyst (Table 1). Once
pancreatic cyst is identified by an imaging modality, the
most important question is to differentiate pseudocyst
from other cystic lesions of the pancreas (Table 2).
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Table 2 Differential diagnosis of cystic pancreatic lesions
Prevalent age
Sex
Presentation
Location
Malignant potential
SCA
MCN
IPMN
SPN
Pseudocyst
Middle age
Mostly female
Mass/pain
Evenly
Very low
Middle age
Mostly female
Mass/pain
Body/tail
Moderate to high
Elderly
Male > female
Pancreatitis
Head
Low to high
Young
Mostly female
Mass/pain
Evenly
Low
Variable
Male > female
Pain
Evenly
None
SCA: Serous cystadenoma; MCN: Mucinous cystic neoplasm; IPMN: Intraductal papillary mucinous neoplasia; SPN:
Solid pseudopapillary neoplasm.
HISTORY AND PHYSICAL EXAMINATION
No specific set of symptoms is specific for pseudocysts;
however, one should consider the possibility of a
pseudocyst in a patient who has persistent abdominal
pain, anorexia, or abdominal mass after a case of
pancreatitis. Rarely, patients present with jaundice or
sepsis from an infected pseudocyst [16]. Occasionally,
even patients with large pancreatic pseudocyst are
asymptomatic. In patients presenting with pancreatic
cyst incidentally discovered on imaging, a crucial point
is to define whether the patient has had prior history
of pancreatitis. The sensitivity of physical examination
findings is limited. Patients frequently have a tender
abdomen. They can occasionally have a palpable
abdominal mass. Peritoneal signs suggest rupture of the
cyst or infection. Other possible findings include fever,
scleral icterus or pleural effusion[17].
LABORATORY EVALUATIONS
Serum tests have limited utility. Amylase and lipase levels
are often elevated, but may be within reference ranges.
The serum bilirubin and liver chemistries may be elevated if the bile duct is obstructed from stone, extrinsic
compression from the pseudocyst or from underlying
liver disorder (e.g. alcoholic hepatitis). Some laboratory
tests may provide clues to the underlying etiology of
pancreatitis (e.g. elevated triglycerides or calcium level).
Elevated liver chemistries raise the suspicion for biliary
pancreatitis.
IMAGING MODALITIES
Transabdominal ultrasound (US)
Pancreatic pseudocyst appears as an echoic structure
associated with distal acoustic enhancement on US
examination. They are well defined and round or oval,
and they are contained within a smooth wall. During
the early phases of their development, pseudocysts
can appear more complex, with varying degrees of
internal echoes. Usually, this appearance results from
the presence of necrotic debris and is more common in
pseudocysts that form as a result of acute necrotizing
pancreatitis than in chronic pancreatitis related
pseudocysts. The debris is cleared over time in most
cases. The pseudocyst can appear more complex in two
other instances: when hemorrhage occurs into the cyst
or when infection of the cyst complicates the clinical
course. Color Doppler or duplex scanning should always
be performed in cystic lesions to ensure that the lesion
in question is not a giant pseudoaneurysm. Sensitivity
rates for US in the detection of pancreatic pseudocysts
are 75% to 90%. Therefore, US is inferior to CT,
which has a sensitivity of 90% to 100%. US has several
limitations, as compared with CT, in the initial diagnosis
of a pseudocyst: the presence of overlying bowel gas
decreases the sensitivity of US, and unlike CT, US
examinations are highly operator dependent[19].
CT
The identification of a thick-walled, rounded, fluid-filled
mass adjacent to the pancreas on an abdominal CT scan
in a patient with a history of acute or chronic pancreatitis is virtually pathognomonic for pancreatic pseudocyst.
Positive CT findings in this clinical situation do not require confirmation with another diagnostic modality. In
the acute setting, a CT scan is the better choice because
significant amounts of bowel gas resulting from ileus or
obstruction decrease the sensitivity of US. In addition,
CT scans provide more detailed information regarding
the surrounding anatomy and can demonstrate additional pathology, including pancreatic duct dilatation and
calcifications, common bile duct dilatation, and extension of the pseudocyst outside the lesser sac. The major
weakness of CT scanning is the relative inability to differentiate pseudocyst from cystic neoplasm, especially
mucinous cystadenomas and intraductal papillary mucinous neoplasm (IPMN)[20]. Furthermore, the intravenous
contrast administered at the time of CT can precipitate
or worsen kidney dysfunction.
Magnetic resonance imaging (MRI)
MRI and magnetic resonance cholangiopancreatography
(MRCP) are sensitive diagnostic modalities for pancreatic
pseudocysts. They are generally not routinely used
because CT scanning typically offers all the diagnostic
information that is required. However, the increased
contrast provides for better characterization of fluid
collections. MRI or MRCP is superior to CT in depicting
debris within fluid collections and pseudocysts. On T2weighted images, a fluid-filled cystic mass produces
high signal intensity and appears bright. The pancreatic
duct and biliary systems are easily visualized in detail,
although interpreting the status of pancreatic duct
integrity may be difficult[21].
The ability of MRI/MRCP to depict choledocholithiasis
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Table 3 Cystic fluid analysis in cystic pancreatic diseases
CEA
CA125
CA19-9
Amylase
Lipase
SCA
MCN
MCAC
Pseudocyst
Low
Variable
Variable
Low-high
Low
High
Variable
Variable-high
Low-high
Low
High
High
Variable-high
Low-high
Low
Low
Low
Variable
High
High
SCA: Serous cystadenoma; MCN: Mucinous cystic neoplasm; MCAC:
Mucinous cystadenocarcinoma
is far superior to that of CT or US. Furthermore, MRCP
techniques can also depict subtle branch-chain dilatation
in chronic pancreatitis. MRI is also highly sensitive to
detect bleeding with complex fluid collections.
Endoscopic retrograde cholangiopancreatography
(ERCP)
ERCP is not necessary in diagnosing pseudocysts, but
can provide definitive therapy in some cases. It also
can be useful in planning possible drainage strategy.
A study by Nealon et al [22] investigated the use of
ERCP and the treatment of pseudocysts and acute
pancreatitis and reported that ERCP findings may
influence the treatment plan. Some authors, therefore,
recommend performing an ERCP before contemplated
surgical procedures. We believe that with the advent of
alternative imaging technology [(CT, MRI, MRCP and
endoscopic ultrasound (EUS)] ERCP is not necessary
in most cases, but this has not been formally tested in a
prospective study.
EUS
EUS is usually used as a secondary test to further evaluate pancreatic cyst detected by other imaging modality (US, CT or MRI). EUS is the test of choice when
attempting to distinguish pancreatic pseudocyst from
other cystic lesions of the pancreas. Visualization of the
pancreas via EUS provides high quality images due to
the close proximity of the ultrasound transducer to the
area of interest. Criteria suggestive of cystic neoplasm
include a cyst wall thickness of greater than 3 mm, macroseptation (all cystic components more than 10 mm),
the presence of a mass or nodule, and cystic dilation
of the main pancreatic duct[23-25]. Fine needle aspiration
(FNA) of the cyst can be performed at the time of EUS
and cyst fluid obtained for laboratory evaluation (see
laboratory evaluation above). EUS can also be used to
guide therapeutic endoscopic drainage.
Analysis of the cyst fluid may help differentiate pseudocysts from cystic tumors of the pancreas (Table 3).
The preferred modality to obtain cystic fluid for analysis
is EUS. Carcinoembryonic antigen (CEA) level in the
cystic fluid is the marker most commonly used. It is low
in pseudocysts and serous cystadenomas and elevated in
mucinous cystadenomas. A CEA level of greater than
400 ng/mL within the cyst fluid strongly suggests mucinous lesion[23,24,26]. Amylase levels are usually high in
pseudocysts and low in serous cystadenoma. Cytology
is occasionally helpful, but a negative result does not exclude malignancy.
Hammel et al[27] published a study to assess the reliability of preoperative biochemical and tumor marker
analysis in cyst fluids obtained by FNA for pathological diagnosis. Cyst fluid was obtained preoperatively by
FNA, and biochemical and tumoral marker values were
measured. The diagnosis of cystic tumors (seven serous
cystadenomas and 12 mucinous tumors) was established
by surgical specimen analysis. Thirty-one pancreatic
pseudocysts complicating well-documented chronic pancreatitis were also studied. The results showed that carbohydrate antigen 19-9 levels of > 50 000 U/mL had a
75% sensitivity and a 90% specificity for distinguishing
mucinous tumors from other cystic lesions. CEA levels
of < 5 ng/mL had a 100% sensitivity and an 86% specificity for distinguishing serous cystadenomas from
other cystic lesions. Amylase levels of > 5000 U/mL
had a 94% sensitivity and a 74% specificity for distinguishing pseudocysts from other cystic lesions. His conclusion was: high carbohydrate antigen 19-9, low CEA,
and high amylase levels in cyst fluid are very indicative
of mucinous tumors, serous cystadenomas, and pseudocysts, respectively[27].
Sperti et al[28] published a study that was performed
to evaluate the utility of serum and cyst fluid analysis for
enzymes (amylase and lipase) and tumor markers (CEA,
CA 19-9, CA 125, and CA 72-4) in the differential diagnosis of cystic pancreatic lesions. In the study, serum and
cyst fluid were obtained from 48 patients with pancreatic
cysts (21 pseudocysts, 14 mucinous cystic neoplasms, six
ductal carcinomas, and seven serous cystadenomas), observed between 1989 and 1994. The results showed that
serum CA 19-9 levels were significantly higher in ductal
carcinomas (all > 100 U/mL) and mucinous cystic neoplasms (P < 0.05). CA 72-4 cyst fluid levels were significantly higher in mucinous cystic tumors (P < 0.005),
with 95% specificity and 80% sensitivity in detecting
mucinous or malignant cysts. A combined assay of serum CA 19-9 and cyst fluid CA 72-4 correctly identified
19 of 20 (pre-) malignant lesions (95%), with only one
false-positive result (3.6%). Cytology showed a sensitivity
of 48% and specificity of 100%. Their conclusion was
that any pancreatic cyst with high serum CA 19-9 values,
positive cytology, or high CA 72-4 in the fluid should be
considered for resection[28].
Khalid et al[29] published a prospective study of the
utility of molecular analysis of the pancreatic pseudocyst. In the study, endoscopic ultrasound-guided pancreatic cyst aspirates were prospectively collected during
a period of 19 mo and studied for cytology, CEA level,
and molecular analysis. Molecular evaluation incorporated DNA quantification (amount and quality), k -ras
point mutation, and broad panel tumor suppressor
linked microsatellite marker allelic loss analysis by using
fluorescent capillary electrophoresis. The sequence of
mutation acquisition was also calculated on the basis of
a clonal expansion model, and comparison was made
to the final pathology. Thirty-six cysts with confirmed
histology were analyzed. There were 11 malignant, 15
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premalignant, and 10 benign cysts. Malignant cysts
could be differentiated from premalignant cysts on the
basis of fluid CEA level (P = 0.034), DNA quality (P
= 0.009), number of mutations (P = 0.002), and on the
sequence of mutations acquired (P < 0.001). Early k -ras
mutation followed by allelic loss was the most predictive
of a malignant cyst (sensitivity, 91%; specificity, 93%).
The study concluded that malignant cyst fluid contains
adequate DNA to allow mutational analysis. A first hit
k -ras mutation followed by allelic loss is most predictive
of the presence of malignancy in a pancreatic cyst. This
approach should serve as an ancillary tool to the conventional work-up of pancreatic cysts. Cumulative amount
and timing of detectable mutational damage can assist in
diagnosis and clinical management[29].
TREATMENT OF PANCREATIC
PSEUDOCYST
January 7, 2009
Volume 15
Number 1
have larger pancreatic pseudocysts than the patients
managed successfully nonoperatively (6.9 cm vs 4.9 cm),
no serious complications occurred in seven patients with
pancreatic pseudocysts greater than 10 cm who were
treated expectantly[32].
Several studies have indicated that the size of the
cyst and the length of time the cyst has been present are
poor predictors of potential for pseudocyst resolution
or complications, but in general, larger cysts are more
likely to become symptomatic or cause complications[33].
However, some patients with larger collections do
well; therefore, size of the pseudocyst alone is not an
indication for drainage[34,35]. The two main indications
for invasive intervention are the presence of symptoms
or the presence of complications (infection, bleeding,
gastric outlet or biliary obstruction).
DRAINAGE PROCEDURES
Supportive medical care
Intravenous fluids, analgesics and antiemetics are
routinely given. For patients that can tolerate oral intake,
low fat diet is recommended. In patients that cannot
tolerate oral nutrition, support can be provided via nasoenteral feeding or total parenteral nutrition (TPN). To
date, no studies have compared these two approaches
in the seating of pancreatic pseudocyst and choice is
based on availability and local preferences. If one can
extrapolate from studies comparing the two modalities
in the seating of acute necrotizing pancreatitis, one can
expect that jejunal feeding will be related with fewer
complications (infection), but may not be able to provide
as much calories as TPN.
The rationale of using octreotide as a therapy
for pancreatic pseudocyst is that it will decrease
pancreatic secretions and aid in pseudocyst resolution.
Unfortunately, this strategy has not been rigorously
tested and only a handful of case series have been
published[30,31].
Most pseudocysts resolve with supportive medical
care. Vitas et al[32] followed over a period of 5 years 114
patients with the diagnosis of pancreatic pseudocyst.
Forty-six patients underwent primary operative therapy,
with 13% undergoing emergency operations for
pseudocyst-related complications. Although no operative
deaths occurred, significant morbidity occurred in
26% of patients (emergency operations, 67%; elective
procedures, 10%). The remaining 68 patients were
initially treated with a nonoperative, expectant approach.
Severe, life-threatening complications in this group
(follow-up for a mean of 46 mo) occurred in only six
patients (9%); 19 patients eventually underwent elective
operation directed at either the pseudocyst or other
complications related to pancreatitis. Overall, in patients
managed by a nonoperative approach, resolution of
the pseudocyst occurred in 57% of the 24 patients
with satisfactory radiographic follow-up, with 38%
resolving more than 6 mo after diagnosis. Although
patients eventually undergoing operation tended to
Symptomatic pseudocysts or the presence of some
complications (infected pseudocyst, gastric outlet
or biliary obstruction) are the main two indications
for some type of drainage procedure. To date, no
prospective controlled studies have compared directly
percutaneous, surgical and endoscopic drainage
approaches. As a result, the management varies based
on local expertise but in general endoscopic drainage is
becoming the preferred approach.
Percutaneous drainage
External drainage can be achieved using CT or US
guidance. With this technique, a drainage pigtail catheter
is placed percutaneously into the fluid cavity and fluid
is drained. Three-dimensional ultrasonography has
been reported useful for the guidance of catheters
into cyst cavities and avoiding vessels[36]. The fluid is
collected over several weeks into an external collection
system. When the drainage output becomes minimal,
the catheter is removed. Contrast injection into the cyst
cavity will demonstrate the size of the remaining cavity
and this finding can be used to monitor the progress.
This technique is successful at resolving pseudocysts, but
it has a high risk of infections. The external drain tends
to create significant patient discomfort. Furthermore,
the catheter tends to clog and may require repositioning
and exchange. The reported long-term success rate
for pseudocyst resolution for US-guided pseudocyst
drainage is around 50%. Unsuccessful drainages are
usually caused by large ductal leaks or obstruction of the
main pancreatic duct. Percutaneous catheter drainage
is contraindicated in patients who are poorly compliant
and cannot manage a catheter at home. It is also
contraindicated in patients with strictures of the main
pancreatic duct and in patients with cysts containing
bloody or solid material[37,38].
Surgical drainage
Surgical drainage of pseudocysts is accomplished by
providing a communication between the pseudocyst
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B
C
D
43
Figure 1 EUS and fluoroscopic image. A: EUS image of pseudocyst with FNA
needle; B: Fluoroscopy image of pseudocyst with FNA needle; C: Fluoroscopy
image of balloon dilating the cyst gastrostomy tract; D: Fluoroscopic image of
two double pigtail stents draining the pseudocyst cavity.
cavity and the stomach or small bowel. This approach to
drainage is often reserved for those patients that cannot
tolerate or have failed percutaneous or endoscopic
drainage. The surgical stoma should be placed in the
most dependent portion of the cystic cavity in order to
maximize the chances of complete drainage. The stoma
usually remains patent and functional for several months.
Adams and Anderson published findings from
a retrospective analysis of 94 patients [39]. The study
population consisted of 42 patients undergoing
internal surgical drainage and 52 patients undergoing
percutaneous pseudocyst drainag e. Significant
complications occurred in 16.7% of the patients
undergoing surgery and in 7.7% of the patients
undergoing percutaneous drainage (P > 0.05). A
subsequent operation was required in 9.5% of the
surgical group and 19.2% of the percutaneous drainage
group (P > 0.05). A significantly higher mortality rate
was associated with surgical therapy (9%) than with
percutaneous therapy (1%) (P < 0.05)[39].
Endoscopic drainage
Endoscopic drainage of pseudocysts is becoming the
preferred therapeutic approach because it is less invasive
than surgery, avoids the need for external drain and has
a high long-term success rate. Drainage is accomplished
with either a transpapillary approach with ERCP or
direct drainage across the stomach or duodenal wall. A
transpapillary approach is used when the pseudocyst
communicates with the main pancreatic duct, usually in
the genue of the pancreatic duct. This approach is also
successful for patients with pancreatic duct disruption.
A transgastric or transduodenal approach is used
when the pseudocyst is directly adjacent to the gastroduodenal wall. To determine the size and location of
the pseudocyst, and to measure the thickness of the
pseudocyst wall, EUS has become the test of choice. A
distance between the gastric or duodenal wall and cyst wall
of more than 1 cm or the presence of large intervening
vessels or varices are relative contraindications for
endoscopic drainage[40,41]. Transgastric or transduodenal
stenting of pseudocysts may be performed using an
endoscopic approach under fluoroscopic guidance
or using EUS to introduce the guidewire into the
pseudocyst cavity.
The endoscopic approach is dependent upon the
presence of a bulge into the lumen of the stomach
or duodenum in order to determine the entry site for
catheterization. This approach has several inherent risks,
including missing the pseudocyst, injuring intervening
vessels, and sub-optimal placement of the drainage
catheter[42]. Therapeutic echoendoscopes now make it
possible to treat pseudocysts with EUS-guided transmural
stenting[43]. Several series have described the deployment
of a 7 Fr stent that is introduced with a needle knife
catheter[44]. A new large-channel echoendoscope allows the
use of 10 Fr stents across the stomach or duodenum[45].
The exact technique for transmural pseudocyst
drainage has not been standardized. In our institution, we
prefer a combined EUS/fluoroscopy guided technique.
The linear therapeutic channel EUS endoscope is used
to detect an optimal site of apposition of pseudocyst
and gut wall, free of intervening vascular structures
(Figure 1A). The 19 Fr gauge EUS FNA needle is then
advanced into the cyst cavity under real-time ultrasound
guidance. The needle position is then located under
fluoroscopy (Figure 1B). After the pseudocyst cavity
has been entered, fluid is aspirated and a floppy-tip
0.035 guide wire is advanced via the needle and under
fluoroscopic control is curled few times into the cyst
cavity. The cyst-gastrostomy (duodenostomy) fistula
tract is then pneumatically dilated, with 8 to 15 mm
biliary balloon dilators (Figure 1C). The size of the
balloon used for dilation is arbitrarily determined based
on the size of the cyst, proximity of vessels, presence
of necrotic debris in the cyst cavity, viscosity of the
aspirated pseudocyst fluid and the presence of infection.
In an attempt to decrease the risk of bleeding we try to
avoid using electrocautery to create the fistulous tract.
In a rare occasion, when the pseudocyst wall is very tick
and the balloon dilator cannot be advanced, we use the
Cystotome (Cook Medical, Winston-Salem, NC, USA).
We will then stent the tract with two or more double
pigtail stents (7F-10F) via the EUS scope (Figure 1D).
In a small series, the EUS approach has resulted in a
success rate of more than 90% in patients with chronic
pseudocysts[46]. The recurrence rate after endoscopic
drainage is low, 4%, and the complication rate is less
than 16%[47].
EUS is also capable of guiding the drainage of
infected pseudocysts using naso-cystic drains[48]. It may
even be possible to drain infected necrotic pancreatic
tissue using EUS and endoscopic techniques[49].
Hookey et al [50] published a chart review and
prospective follow-up for 116 patients with attempted
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endoscopic drainage of symptomatic pancreatic-fluid
collections (pseudocysts and organized pancreatic
necrosis). A total of 116 patients presented with fluid
collections classified as acute fluid collection (n = 5),
necrosis (n = 8), acute pseudocyst (n = 30), chronic
pseudocyst (n = 64), and pancreatic abscess (n = 9).
The median diameter of the collection drained was 60
mm (15-275 mm). Median follow-up after drainage was
21 mo. The drainage technique was transpapillary in 15
patients, transmural in 60, and both in 41. Successful
resolution of symptoms and collection occurred in
87.9% of cases. No difference in success rates was
observed between patients with acute pancreatitis and
those with chronic pancreatitis. However, drainage of
organized necrosis was associated with a significantly
higher failure rate than other collections. No significant
differences were observed regarding success when
disease, drainage technique, or site of drainage was
considered. Complications occurred in 13 patients
(11%), and there were six deaths in the 30 d after
drainage, including one that was procedure related. He
concluded that endoscopic drainage of pancreatic-fluid
collections is successful in the majority of patients and is
accompanied by an acceptable complication rate[50].
Muscatiello et al[51] published a case report of alcohol
use for the treatment of a pancreatic pseudocyst. In
his report, aspiration of the pancreatic pseudocyst was
started, and after an apparent reduction in the volume of
the pseudocyst by about 30%, 30 mL of absolute ethanol
diluted 1:1 with saline was injected and maintained for
about 10 min. Aspiration then continued until EUS
imaging showed that the cyst was completely empty. CT
24 h later demonstrated no complications and confirmed
that the procedure had been successful. Culture of the
aspiration fluid identified a Pseudomonas aeruginosa and
Citrobacter freundii complex. Cytological examination
did not show any neoplastic cells. The patient was
discharged on the seventh day with no symptoms and
with normal laboratory tests. It seems that, in addition to
causing sclerosis of the cystic wall, ethanol contributes
to sterilizing the infected fluid collection. In that case,
a long follow-up period (18 mo) in which there was
no recurrence of the pseudocyst confirms that this
procedure may be useful in the treatment of organized
necrotic abscesses and pancreatic abscesses when there
is no communication with the pancreatic duct[51].
In a large retrospective analysis of 603 patients who
were undergoing EUS-FNA of pancreatic cysts, possible
infection developed in only a single patient. The majority
of patients in this series (90%) received antibiotic
prophylaxis, most commonly a fluoroquinolone given
for 3 d after the procedure, and this may possibly explain
the low infection rate. The benefit of prophylactic
antibiotics before an FNA of cystic lesions has not been
evaluated by prospective randomized studies[52].
The ASGE, in 2008, published the guidelines for
prophylactic use of antibiotics for GI endoscopy.
According to these guidelines, prophylaxis with an
antibiotic, such as a fluoroquinolone administered before
EUS-FNA of cystic lesions along the GI tract including
January 7, 2009
Volume 15
Number 1
pancreatic cyst. Antibiotics may be continued for 3 to
5 d after the procedure (supported by observational
studies). When antibiotic prophylaxis is administered, a
fluoroquinolone administered before the procedure and
continued for 3 d after the procedure is a reasonable
regimen[53].
Cahen et al [54] published a retrospective study to
evaluates the short-term and long-term results with
the endoscopic drainage of pancreatic pseudocyst and
aimed to identify procedural modifications that may
improve its safety and efficacy. A total of 92 patients
were included (66 men, 26 women; median age 49 years).
The technical success rate of the drainage procedure
was 97% and the mortality rate was 1%. Complications
occurred in 31 patients (34%), eight of which (9%)
were major and required surgery: hemorrhage in four
cases (three of which were caused by erosion of a
straight endoprosthesis through the cyst wall), secondary
infection in three, and perforation in one. During a
median follow-up period of 43 mo, 10 patients (11%)
underwent additional (nonendoscopic) treatment for a
persistent cyst and five (5%) for a recurrent cyst. Overall,
endoscopic drainage was successful in 65 patients (71%).
He concluded that endoscopic drainage is an effective
treatment for pancreatic pseudocysts and offers a
definitive solution in almost three-quarters of the cases.
The majority of major complications might have been
prevented by using pigtail stents instead of straight
stents and by taking a more aggressive approach to the
prevention and treatment of secondary cyst infection[54].
COMPLICATIONS OF PANCREATIC
PSEUDOCYST
Splenic complications
Splenic complications of pseudocyst include massive
hemorrhage into the pseudocyst, sepsis with splenic
infarction, and splenic vein thrombosis. The diagnosis
of intrasplenic pseudocyst, based on clinical findings
alone, is difficult to arrive at but should be suggested
by the presence of a mass in the left upper quadrant.
Sonography and computerized axial tomography may be
particularly helpful in confirming splenic involvement.
Selective celiac arteriography should be performed
whenever splenic involvement is suggested in order to
confirm the diagnosis and to search for pseudoaneurysm
formation. Urgent surgical intervention is usually
warranted in view of the high incidence of serious
compl icat ions and t he propensit y toward rapid
clinical deterioration. Resection of the pseudocyst by
splenectomy and distal pancreatectomy is the treatment
of choice[55].
Rupture
Rupture of a pseudocyst can have either a favorable or
an unfavorable outcome and this depends on whether it
ruptures into the gastrointestinal tract, into the general
peritoneal cavity or into the vascular system [56,57 ] .
Rupture into the gastrointestinal tract either results
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Habashi S et al . Pancreatic pseudocyst
45
in no symptoms or leads to melaena or hematemesis
that usually requires urgent measures. Rupture into the
general peritoneal cavity results in features of peritonitis
and occasionally hemorrhagic shock. Emergent surgical
exploration is usually required. While an internal
drainage should always be aimed for, usually a thorough
abdominal lavage and external drainage is all that can
be achieved safely.
Hemorrhage
Hemorrhage can greatly complicate the course of a
pseudocyst[58]. The morbidity and mortality is very high
because it can appear without warning and is usually
due to erosion of a major vessel in the vicinity of
the pseudocyst. Interventional radiology can play an
invaluable role both in locating the source of bleeding
and in embolisation of the bleeding vessel[59]. Without
prior information of the bleeding point, surgical
exploration can be hazardous and challenging.
Infection
Infection occurs either spontaneously or after
therapeutic or diagnostic manipulations. While infected
pseudocyst can initially be treated with conservative
means, a majority of patients will require intervention.
Traditionally surgery has been the preferred modality
but endoscopic treatment is gaining acceptance[48,60]. An
external drainage may be necessary in selected situations
such as when there is evidence of gross sepsis and the
patient is too unstable to undergo surgical or endoscopic
drainage.
Biliary complications
Biliary complications occur due to a large cyst in
the pancreatic head region obstructing the common
bile duct and resulting in obstructive jaundice [61,62].
Therapeutic endoscopy with short-term biliary stenting
is valuable in this situation. It can be retained until either
the pseudocyst resolves or is treated by intervention.
Portal hypertension
Portal hypertension can result from compression or
obstruction of the splenic vein/portal vein either by
the cyst alone or in conjunction with underlying chronic
pancreatitis[63]. In this situation, surgery appears to be
the only treatment modality available and an appropriate
surgical procedure can effectively treat this form of
portal hypertension.
CONCLUSION
Pancreatic pseudocysts are the result of acute or
chronic pancreatitis and are the most common cystic
lesions of the pancreas, accounting for 75%-80%
of such lesions. The most common symptoms are
abdominal pain, nausea and vomiting, although they
can be asymptomatic. Abdominal CT is an excellent
choice for initial imaging. EUS plays an important
role in differentiating pseudocyst from other cystic
lesions of the pancreas and can greatly assist in
transmural endoscopic drainage. Initial management
consists of supportive care. Persistent symptoms and
the development of complications warrant invasive
intervention. The surgical, percutaneous and endoscopic
pseudocyst drainage procedures have not been directly
compared in high quality prospective randomized
studies and the preferred approach varies based on
patient preferences and local expertise. In recent years,
the endoscopic approach has gained popularity with
surgery reserved for patients who had failed endoscopic
or percutaneous drainage. A tailored therapeutic
approach taking into consideration patient preferences
and involving multidisciplinary team of therapeutic
endoscopist, interventional radiologist and pancreatic
surgeon should be considered in all cases.
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S- Editor Xiao LL L- Editor Rippe RA E- Editor Yin DH
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